The View From Here

Fred Graham, Sandra Jeavons, Liz Miles and Elizabeth Beattie introduce The View From Here, an evidence-based online training package suitable for all Australian hospitals to use in preparing their staff to provide quality care for patients with dementia

Dementia Training Australia’s (DTA’s) The View From Here (TVFH) e-learning course delivers dementia education specific to acute care: the setting where older people are the highest users of services. Designed to help health professionals recognise, understand and respond to the unique needs of patients with dementia in their care, it provides a flexible, accessible learning package with tools and strategies to support practice change.

This article explains what the course is, where it came from and how it is being used in assisting hospital staff to understand and work with people with dementia. Staff from four hospitals also share their experiences, impressions and outcomes of implementing the course – their view.

The View From Here delivers education specific to acute care to better prepare hospital staff to provide high-quality care for people with dementia

Background

TVFH is an educational resource specifically designed to address an identified need: to better prepare hospital nurses for delivery of high-quality care for people with dementia. Although people with dementia are significant users of hospital services, there is serious concern that hospital staff and systems are not well prepared, designed or equipped to meet the needs of those with dementia (ACSQHC 2014). The incidence of dementia in hospital patients aged over 70 years is high: approximately 20-25%, increasing to 47% in those aged over 90 (Travers et al 2013) and these numbers are predicted to increase.

Compared to people without dementia, people with dementia are more likely to be admitted to hospital for treatable conditions such as constipation, respiratory and urinary tract infections, hip fractures and delirium (Draper et al 2011). At the same time, people who present with dementia alongside other health conditions have a higher risk of experiencing adverse outcomes such as iatrogenic infections and complications, injuries from falls, and longer length of stay compared to patients who do not have dementia (ACSQHC 2013).

Many of these complications are likely to be preventable and responsive to nursing interventions (Bail et al 2013). However, many nurses in hospitals have little or no dementia training and lack confidence in providing care for people with dementia (Gandesha et al 2012; Travers et al 2013).

Although dementia may not be the primary reason for an admission to hospital, people with dementia require support and understanding with a range of issues related to their dementia, including difficulties with communication (Talerico et al 2002), increased sensitivity to high and low stimulation (Kovach & Wells 2002), sensory and perceptual changes, and responsive behaviours that can often lead to disruptions in medical and nursing treatments (Hessler et al 2017; Sampson et al 2014).

Moreover, people with dementia have up to five times the risk of developing delirium in hospital, an acute deterioration in cognition, which further compounds their care needs (Fick et al 2002; Fick et al 2013). A lack of staff skill and training around these issues is linked with chemical and physical restraint overuse and a custodial approach to special observation or ‘specials’, which often fails to utilise therapeutic psychosocial care opportunities afforded by one-to-one care (Dewing 2013; Moyle et al 2010). Dementia-specific education and training are known to improve knowledge, attitudes and confidence of health-care staff (Eggenberger et al 2013; Scerri et al 2016; Travers et al 2013).

The View From Here topics

Neuropathology: introduces the basic neuropathology of dementia and responsive behaviour

Delirium and delirium superimposed on dementia: introduces the symptoms of delirium and how they compare with dementia

Person-centred care and theoretical models: provides a brief overview of person-centred care and three theoretical models to help put the focus on the person with dementia

Communication strategies: an overview of the communication changes usually experienced by patients with dementia and some simple strategies to help communicate effectively

Approaches to pain assessment: introduces pain in the context of dementia and aims to help health professionals recognise the links between the experience of pain and the presence of responsive behaviours

Activities for the acute care setting: introduces the concept of engaging people with dementia in activity as an important therapeutic care intervention that may reduce distressing symptoms involving behaviour as well as improve mood and well-being

The environment: sensory, physical, social: introduces a range of environmental factors that impact on the well-being and function of a person with dementia during an acute care stay

Care planning and interventions: draws together the learnings from topics 1-8 and leads participants through planning care and implementing pharmacological and non-pharmacological strategies that will lead to optimal care for patients with any form of cognitive impairment.

The view from Maryborough Hospital

As part of a dementia support project we undertook a Tailored Training Package with Dementia Training Australia (DTA). DTA conducted a training needs analysis for our sub-acute ward. Education for staff was identified as a high priority and we were excited to discover The View From Here (TVFH) was being released. We were seeking training that would give staff understanding of the physiological and clinical aspects of dementia in order to assist them to see beyond behaviours and consider the underlying pathological processes of dementia. We also wanted training that would take participants on a journey and build empathy for the experience of people with dementia.

Since undertaking TVFH, when on the ward, we now hear staff speaking about the specific type of dementia a person has and how this is affecting their behaviour. Staff are taking a more person-centred approach to address the needs of individual patients and not taking a ‘one-solution-fits-all’ approach to people with dementia.

One of our dementia support project goals was to improve interdisciplinary relationships. Clinical nurses, registered nurses, enrolled nurses, assistants in nursing, allied health professionals, allied health assistants, allied health managers and our Director of Allied Health have all participated in TVFH. Having staff at so many levels complete the same content means there is more advanced understanding of dementia across the interdisciplinary team. This had led to more solution-focused discussions around care and greater effort in implementing non-pharmacological interventions for responsive behaviours.

The benefits of TVFH in improving patient care have been so great that work is now under way to have TVFH included in our internal training portal. From 2018, TVFH will be mandatory for all new nursing and allied health staff. Most importantly, our patients with dementia are receiving better care.

The View From Here reinforces practice initiatives including routine use of the Sunflower chart for gathering and accessing key patient information

Content

As its name suggests, The View From Here encourages the learner to understand the experience of a busy hospital from the patient’s perspective. The content is presented through the lens of people living with dementia as they interpret what is happening for them and express what they need in the unfamiliar physical and social environment they find themselves in. For instance, sound and visual effects in videos used in the course simulate the sensory experience of someone with dementia and/or delirium in this setting. Putting the patient’s perspective foremost underpins learning and supports a person-centred approach to care.

The design of TVFH caters to the differing learning styles of adult learners, within the context of an online environment. The visual, interactive course includes infographics, click and reveal, reflection points, and video case studies depicting hospital ward scenarios and interactions. Content also includes assessments and implementation strategies, with links and downloads of tools and other resources.

The nine topics (see The View From Here topics box) each take about 30 minutes to work through online, plus time for additional reading and practise in using the tools. Certificates of completion demonstrate successful completion for the purpose of continuing professional development (CPD) that also provide educators with evidence for meeting national standards requirements.

Development

TVFH was originally developed by the Queensland Dementia Training Study Centre as a face-to-face, facilitator-led education program to improve the quality of care of patients with dementia in a large urban hospital (for more on development see Nayton et al 2014). The program aimed to provide the staff with evidence-based assessment and observation techniques to facilitate an understanding of the needs and experiences of acutely ill patients with dementia and was developed through a comprehensive and iterative process drawing from multiple inputs.

While the course was successful, its mode of delivery was considered resource-intensive, time-consuming and therefore difficult to replicate across hospital wards and in hospitals nationally. An e-learning platform was decided on as the most sustainable, accessible and suitable method for roll-out to acute care organisations.

An expert working group comprising industry representatives, acute care dementia specialists, learning and instructional designers and online education developers reformulated core content into an online course, ensuring it was interactive, engaging and appropriate to the work setting.

To ensure content was accurate and appropriately pitched, a national panel of clinical experts reviewed each topic as it was redeveloped. Feedback from this group led to the inclusion of two additional topics. While the nine-topic design of the course is extensive it was seen as necessary, given the lack of dementia and delirium content in undergraduate university programs.

Ways to use TVFH

Cognitive impairment is explicitly included in the newly developed Comprehensive Care Standard in the second version of the National Safety and Quality Health Service Standards (NSQHS). As such, hospitals are required to show how they have prepared staff to provide quality care for people with cognitive impairment, dementia and delirium. As a virtual e-learning package, TVFH provides an ‘off the shelf’ and ‘fit-for-purpose’ evidence-based training package suitable for all Australian hospitals to use in preparing their staff to provide quality care for patients who have dementia.

The four case studies accompanying this article demonstrate how the course can be used in a variety of ways to underpin education and changes to models of care in hospitals. While the course is specific to dementia, it also includes a topic on delirium superimposed on dementia and provides clinicians with a good appreciation of the difference between dementia and delirium.

Uptake and next steps

To date, about 2200 people have enrolled in TVFH since its launch in April 2017. This includes those who participated in the course at trial hospital sites and as part of a DTA Tailored Training Package (TTP).

At the end of the course users are asked to complete an online Knowledge Translation Survey which looks at translating learning to practice. They are asked to indicate their level of agreement with statements including:

Given me new knowledge about how to care for people with dementia.

Raised my awareness of how to care for people with dementia.

Changed my beliefs in thinking about dementia.

My confidence in caring for a person with dementia has increased.

I have learnt something useful that I can put into practice.

I have improved my skills.

I will use what I have learnt.

I will try a new procedure or technology.

Ninety-eight per cent of the survey respondents strongly agreed/agreed with all statements in the survey.

Following the initial success of TVFH and the positive feedback received from users, the next steps are to:

Enable more flexibility for users by making the course available as nine individual topics, with a certificate of completion provided for each. Topics can then be packaged to best suit individuals’ or organisations’ training needs and schedules. For example, all staff (including general staff) might be required to undertake topics 1 and 2, which are about understanding dementia, while allied health staff might choose topics such as activities for the acute care setting, communication, pain management and environmental design. Clinical staff might be required to undertake all nine topics.

Promote TVFH course directly to hospitals across Australia.

Continue to support the Australian Commission on Safety and Quality in Health Care’s Caring for Cognitive Impairment campaign. The campaign’s website (http://cognitivecare.gov.au/) links to TVFH under the ‘Resources – Online learning‘ section. The campaign helps hospitals meet new comprehensive care national standards to provide better outcomes and experiences for patients with cognitive impairment in hospitals, and for their loved ones and staff who care for them.

The view from Logan Hospital

For Logan Hospital, the opportunity to trial The View From Here (TVFH) online course was timely. Logan Hospital’s Caring for Cognitively Impaired Patients Steering Committee (which includes a consumer representative) had been formed six months earlier to address specific needs and provide a structure for change to improve the care of patients with cognitive impairment. TVFH became a key ingredient to drive that change.

TVFH training was implemented in two medical units, as part of a pre-post quality improvement project. All nurses in one unit and 93% in the other completed TVFH. Feedback from the participants was overwhelmingly positive.

The training reinforced practice initiatives including routine use of the Behaviour Observational Chart and Sunflower chart (see image) that allow staff to gather and access key patient information, and delirium screening. Senior nursing clinicians noted significant changes in staff practice since completing the training course. Staff demonstrated an increased awareness of their own actions while interacting with patients.

Preliminary pre-post quality data suggests positive outcomes with decreased rates of falls and occupational violence and decreased reliance on casual staff across the two medical units.

Both units have recently received recognition for their work, including finalist in the 2017 Queensland Health Awards for Excellence, an award for Outstanding Innovation (Health Round Table 2017), and an award for Putting Ideas Into Action (Metro South Health Services Board Chair’s award).

TVFH has seen staff gain the skills and confidence to provide more meaningful cognitive care. The TVFH topics were relevant to the inpatient setting, and the tools and ideas expanded the range of interventions available to staff when caring for cognitively impaired patients.

TVFH continues to be part of the induction and orientation program for nurses in the two units that originally trialled the course. As of October 2017, 193 nurses had completed TVFH. The Caring for Cognitively Impaired Patients Steering Committee plans to roll it out to other areas of the hospital, such as the Emergency Department, and to broaden the reach to include medical and allied health staff.

The view from Princess Alexandra Hospital

Princess Alexandra Hospital (PAH) in Brisbane has adopted The View From Here (TVFH) as fundamental education for all our graduate nurses working across the hospital and all nursing staff working in three internal medicine unit (IMU) wards. In the IMU, we have been fortunate that one of our wards (Ward 5A) has operated an eight-bed specialised care environment for patients with cognitive impairment since 2008. Many of the resources mentioned in the TVFH course have been developed within this ward.

For us, TVFH provides a highly relevant learning program through which to embed our existing assessment tools and resources into the daily clinical practice and understanding of our nursing staff. On ward 5A, all staff have completed the course and report it as very beneficial, improving their understanding of how to respond to behavioural symptoms, how to identify environmental triggers and unmet needs, and how to provide interactions which are person-centred and meaningful for people with cognitive impairment.

The staff reported that the case studies and video examples were particularly useful to their learning. A hospital-wide cognition champion’s network of over 120 champion nurses at PAH has introduced the Behavioural Observation Chart, Sunflower chart (see image) and recreational resources to many other hospital wards/units, setting up local ‘cognition corners’ to store and promote these resources.

All the IMU wards have a cognition corner and each ward has an expectation that all staff will have completed TVFH learning course within three months of commencing work on the ward.

The e-learning modality of TVFH is complemented by regular in-service training, designed by our education team, that makes use of wearable silicone props (MASK-EDTM (KRS Simulation) for specially designed role-play situations to teach better communication skills, person-centred approaches and behavioural management skills.

TVFH is also integrated into our hospital-wide graduate nurse education program which requires all graduate nurses complete the course within two months prior to their first study day. The first study day supports their learning through a two-hour interactive workshop which teaches delirium screening and management of behavioural crises in people with cognitive impairment. TVFH replaces an existing set of PDF modules and is considered much more interactive and engaging.

While the IMU and graduate program have been early adopters, there are plans for TVFH to be incorporated into a hospital-wide education program for 2018.

The view from Nambour Hospital

The Sunshine Coast Hospital and Health Service (SCHHS) began using The View From Here (TVFH) after Dementia Training Australia (DTA) asked the CNC Gerontology about piloting the e-learning course at Nambour Hospital.

The Practice Development Team (PDT) tested TVFH files to ensure compatibility with our Learning Management System (LMS), before making it available for staff to access. As soon as it was available, TVFH was taken up by the RACF, Cognitive Assessment and Management Unit (CAMU) and one of our medical wards.

The course has now been used for 12 months and we’ve had 100 nurses and 13 social workers, occupational therapists, physiotherapists and allied health assistants complete all nine topics. Another 399 people are enrolled and/or are part-way through the course.

Response to the training has been positive. We believe that framing the course from the perspective of patients with delirium or cognitive impairment struck a chord with staff.

The training has assisted staff in administering the Rapid Assessment Test for Delirium (4AT). In terms of identifying and assessing for delirium, we have developed a Coaching TIP (Teaching in Practice) for the 4AT and also added links to TVFH on our delirium resource page.

TVFH has become a part of the Requisite Training Framework (REF) , or recommended training, for five wards, and the casual pool. Social work and occupational therapy have also placed it on their REF for those working in specific areas. This is an ongoing process and more of the medical wards are recognising TVFH’s value and starting to request it for their REF.

We would like to be able to set specific topics for different staff groups (for example for AINs, RNs and allied health), so it would be good to be able to just do single topics and obtain a completion certificate for each, rather than having to complete the whole nine topics in one go.

The feedback from the staff has been excellent and we believe TVFH is assisting them in their practice.

Aspects of the course that we really liked were:

4AT and delirium.

Thinking about how a patient perceives their surroundings and the fear that they may have.

Conclusion

People living with dementia requiring hospital treatment will receive better care and better outcomes when the staff they encounter recognise, understand and appropriately respond to their unique needs.

Piloting of TVFH demonstrates its applicability and acceptability in the acute care setting for a range of staff. As a comprehensive, evidence-based e-learning course, TVFH is user-ready to help hospitals provide the training their staff need and meet the NSQHS requirements for cognitive care in Australian hospitals.

The experiences of the four hospitals that trialled the course show how it can be implemented into training systems, integrated into induction programs and used as part of a DTA Tailored Training Package.

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